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• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the Plan as a “dependent child.”

[If the Plan provides retiree health coverage, add the following paragraph:]
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a
proceeding in bankruptcy is filed with respect to COMPANY, and that bankruptcy results in the loss of coverage of
any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired
employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy
results in the loss of their coverage under the Plan.

5.4.3 When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been
notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following
qualifying events:
• The end of employment or reduction of hours of employment;
• Death of the employee;
• [add if Plan provides retiree health coverage: Commencement of a proceeding in bankruptcy with respect
to the employer;]; or
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing
eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days [or enter longer
period permitted under the terms of the Plan] after the qualifying event occurs. You must provide this notice to:
[Enter name of appropriate party]. [Add description of any additional Plan procedures for this notice, including a
description of any required information or documentation.]

5.4.4 How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will
be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect
COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their
spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to
employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event
during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify
the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11
months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started
at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-
month period of COBRA continuation coverage. [Add description of any additional Plan procedures for this notice,

Information in this document is proprietary to E3 and should not be discussed with third parties without consent.
Printed copies are uncontrolled and for reference only.